Pneumonia is one of the most common infections that require inpatient care. The documentation of pneumonia needs to be very specific, in order to capture a good reflection of what really happened during the hospitalization. Many different infectious agents can cause pneumonia. The one that is being treated, even if presumptive needs to be documented. The terms “possible”, “probable”, “not ruled” out and “likely“ can always be used. The association with sepsis, respiratory failure and mechanical ventilation, if present, cannot be omitted because they will show the severity of illness and the risk of mortality of the case.

Marco A. Ramos MD, CCDS

In order to quote from this article (using Chicago style) please use the following:

Marco A. Ramos, “Clinical Documentation Improvement Series #10. Documenting Pneumonia”,” SMO Blog (blog), October 8, 2018, https://steemit.com/health/@secondmedicalop/clinical-documentation-improvement-series-8-the-importance-of-present-on-admission

Links to the Previous Posts in this Series

- Clinical Documentation Improvement Series #1. Documenting Acute Respiratory Failure

- Clinical Documentation Improvement Series #2. How and When Do We Use the Body Mass Index (BMI)

- Clinical Documentation Improvement Series #3. Is it Delirium or Encephalopathy?

- Clinical Documentation Improvement Series #4. Documenting Myelopathies and Radiculopathies

- Clinical Documentation Improvement Series #5. Documenting Electrolyte Imbalances.

- Clinical Documentation Improvement Series #6. Documenting Electrolyte Imbalances.

- Clinical Documentation Improvement Series #7. Documenting Electrolyte Imbalances.

- Clinical Documentation Improvement Series #8. The Importance of “Present on Admission”

- Clinical Documentation Improvement Series #9. If the Patient has Elevated Troponins...

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